Emergency Room Overcrowding: Making Ambulance Crews Wait

A patient calls 911. You respond, do an assessment, start an IV, put the patient on your stretcher and head for the emergency room. As you pull up to the emergency room, you see ambulances backed up in the emergency room driveway. This can only mean one thing: The emergency room is overcrowded again and you are facing a one- to four-hour wait with your patient on your stretcher because there are no beds are available in the emergency room.

This not-uncommon phenomenon is playing out across the country. Overcrowding in Boston, Buffalo, Cincinnati, Cleveland, Las Vegas, Los Angeles, Memphis, New York, Philadelphia, Phoenix, Seattle, Tucson and many smaller communities is forcing EMS personnel to sit in emergency rooms for up to six hours waiting to transfer patients to hospital stretchers.

In Memphis, some patients have had to be treated by paramedics as their conditions deteriorated, waited in the back of ambulances for over two hours or underwent emergency procedures while still on fire department stretchers. All of this adds up to EMS systems providing "unpaid labor" to watch over hospital patients.

Causing this "parking" of ambulances are hospital cutbacks and closings, coupled with a shortage of nurses. In essence, hospitals do not have enough emergency room staff or beds to handle the burgeoning visits to emergency rooms. According to one report, in the past 10 years, more than 1,000 hospitals and 1,100 emergency rooms in the U.S. have closed and others have had to cut back on services because of diminished payments from Medicare and managed-care insurance plans.

Worse Yet to Come?

Unfortunately, this situation is not going to get any better soon as the baby boomer population begins to turn 60 this year. These people will require additional health care as they grow older.

To avoid having ambulances sitting in emergency room parking lots for hours, some hospitals divert patients to other hospitals. The only problem is what happens when every hospital in a community is diverting patients? In November 2005, Cleveland saw a third straight monthly record when eight hospitals went on diversion 57 times. Also in November, the Boston area's 27 emergency rooms shut down for a total of 631 hours - nearly twice the 386 hours ambulances were diverted during the previous month. Hospitals in Buffalo report keeping some patients in emergency rooms for more than 24 hours until beds in intensive-care units or on other floors open up.

In response, EMS agencies are taking extraordinary measures to keep ambulances in service. In some Las Vegas hospitals, extra paramedics have been stationed to wait with ambulance patients in emergency rooms so that transporting squads can return to the streets. Other services have put extra ambulance stretchers in emergency rooms so that a patient can remain on the original ambulance stretcher and the EMS crew can return to service with one of the extra stretchers.

But all of this may be illegal.

In December 2005, the Centers for Medicare and Medicaid (CMS) in Region IV (Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina and Tennessee) issued a memorandum stating that the "parking" of EMS patients in hospitals may violate the Emergency Medical Treatment and Active Labor Act (EMTALA). The wording of the memorandum matches that found in another opinion, from the Centers for Medicare and Medicaid Services' Region VI office in Dallas in 2002.

In its opinion, CMS wrote, "CMS has learned that several hospitals routinely prevent Emergency Medical Service (EMS) staff from transferring patients from their ambulance stretchers to a hospital bed or gurney. Reports include patients being left on an EMS stretcher (with EMS staff in attendance) for extended periods of time. Many of the hospital staff engaged in such practice believe that unless the hospital "takes responsibility" for the patient, the hospital is not obligated to provide care or accommodate the patient. Therefore, they will refuse EMS requests to transfer the patient to hospital units.

This practice may result in a violation of the Emergency Medical Treatment and Labor Act (EMTALA) and raises serious concerns for patient care and the provision of emergency services in a community. Additionally, this practice may also result in violation of the Conditions of Participation for Hospitals.

"Under EMTALA, a patient is considered to have "presented" to a hospital when a patient arrives on hospital grounds (defined as the main hospital building and any hospital-owned property within 250 yards of the main hospital building) and a request is made on the individual's behalf for examination or treatment of an emergency medical condition. A patient who arrives via EMS meets this requirement when EMS personnel request treatment from hospital staff. Therefore, the hospital must provide a screening examination and stabilizing treatment, if necessary, to resolve the patient's emergency medical condition. CMS does not recognize the distinction some hospital staff are trying to make in identifying EMS versus hospital responsibility for a patient already in the facility."

A System in Trouble

Later in the document, CMS writes, "Our office recognizes the enormous strain and crowding many hospital emergency departments face every day. However, this practice is not a solution. "Parking" patients in hospitals and refusing to release EMS equipment or personnel jeopardizes patient health and impacts the ability of the EMS personnel to provide emergency services to the rest of the community."

The practice of parking patients in emergency rooms and using EMS equipment and staff to take watch over and, in some cases, render care to patients is becoming more commonplace. Unfortunately, it is a poor practice that robs a community of its EMS resources, delays responses to 911 calls and puts an unnecessary strain on EMS personnel.

If this is a problem in your community, your fire chief or EMS chief should address the issue with hospital administrators. If it is happening at multiple hospitals in your community, it may be necessary to get all the players to the table to find a region-wide solution. The alternative is not attractive. An ambulance sitting in a parking lot for hours with a patient on your stretcher does no good for the patient, EMS personnel or the community.

Gary Ludwig, MS, EMT-P, a Firehouse contributing editor, is a deputy fire chief with the Memphis, TN, Fire Department. He has 28 years of fire-rescue service experience, and previously served 25 years with the City of St. Louis, retiring as the chief paramedic from the St. Louis Fire Department. Ludwig is vice chairman of the EMS Section of the International Association of Fire Chiefs (IAFC), has a master's degree in business and management, and is a licensed paramedic. He is a frequent speaker at EMS and fire conferences nationally and internationally. He can be reached through his website at www.garyludwig.com.